Future Interventional Radiologists and Where to Find Them–Insights from Five UK Interventional Radiology Symposia for Junior Doctors and Medical Students

CardioVascular and Interventional Radiology - The interventional radiology (IR) trainee recruitment in the UK is lagging behind the pace of service expansion and is potentially hindered by...     

A prospective, longitudinal study of the functional status and quality of life of older patients with breast cancer receiving adjuvant chemotherapy

OBJECTIVES: To examine the toxicity experienced by a cohort of older women receiving adjuvant chemotherapy for breast cancer and the longitudinal effect on their functional status and quality of life (QOL). DESIGN: A geriatric assessment measuring functional status, comorbidity, mood, nutritional status, and QOL was performed before chemotherapy, at the end of chemotherapy, and 6 months later. SETTING: This prospective longitudinal study was conducted at Memorial Sloan-Kettering Cancer Center, New York, New York. PARTICIPANTS: Fifty patients aged 65 and older with Stage I to III breast cancer receiving any adjuvant chemotherapy; 49 were evaluable. MEASUREMENTS: The chemotherapy regimen and the toxicity to chemotherapy were recorded. A geriatric assessment was performed before the start of chemotherapy, on completion of chemotherapy, and 6 months after completion of chemotherapy. QOL testing was performed at the same times. RESULTS: Patients (mean age 68, range 65-84) received an anthracycline-based chemotherapy regimen (n=15) or cyclophosphamide 600 mg/m2 intravenously (i.v.), methotrexate 40 mg/m2 i.v., 5-fluorouracil 600 mg/m2 i.v. every 3 weeks for eight cycles (n=34). Grade 3 or 4 toxicity occurred in 53% (n=26), hematological toxicity in 27% (n=13), and nonhematological toxicity in 31% (n=15). Despite toxicity, there was no significant longitudinal change in functional status or QOL. CONCLUSION: Despite toxicity from adjuvant chemotherapy, this cohort of relatively young older patients maintained their functional status and QOL from before chemotherapy to 6 months postchemotherapy. Subtle changes in higher-order functioning would require assessment using different geriatric assessment tools.     

Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study

BACKGROUND:

The authors tested whether an educational video on the goals of care in advanced cancer (life‐prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

METHODS:

A survey of 80 patients with advanced cancer was conducted before and after they viewed an educational video. The outcomes of interest included changes in goals of care preference and knowledge and consistency of preferences with code status.

RESULTS:

Before viewing the video, 10 patients (13%) preferred life‐prolonging care, 24 patients (30%) preferred basic care, 29 patients (36%) preferred comfort care, and 17 patients (21%) were unsure. Preferences did not change after the video, when 9 patients (11%) chose life‐prolonging care, 28 patients (35%) chose basic care, 29 patients (36%) chose comfort care, and, 14 patients (18%) were unsure (P = .28). Compared with baseline, after the video presentation, more patients did not want cardiopulmonary resuscitation (CPR) (71% vs 62%; P = .03) or ventilation (80% vs 67%; P = .008). Knowledge about goals of care and likelihood of resuscitation increased after the video (P < .001). Of the patients who did not want CPR or ventilation after the video augmentation, only 4 patients (5%) had a documented do‐not‐resuscitate order in their medical record (kappa statistic, ?0.01; 95% confidence interval, ?0.06 to 0.04). Acceptability of the video was high.

CONCLUSIONS:

Patients with advanced cancer did not change care preferences after viewing the video, but fewer wanted CPR or ventilation. Documented code status was inconsistent with patient preferences. Patients were more knowledgeable after the video, reported that the video was acceptable, and said they would recommend it to others. The current results indicated that this type of video may enable patients to visualize “goals of care,” enriching patient understanding of worsening health states and better informing decision making. Cancer 2012. © 2012 American Cancer Society.     

Doxorubicin followed by sequential paclitaxel and cyclophosphamide versus concurrent paclitaxel and cyclophosphamide: 5-year results of a phase II randomized trial of adjuvant dose-dense chemotherapy for women with node-positive breast carcinoma.

PURPOSE: We conducted a randomized Phase II trial to directly compare toxicity, feasibility, and delivered dose intensities of two adjuvant dose-intensive regimens containing doxorubicin, paclitaxel, and cyclophosphamide for patients with node-positive breast carcinoma. EXPERIMENTAL DESIGN: Forty-two patients with resected breast carcinoma involving one or more ipsilateral axillary lymph nodes, were randomized to receive two different schedules of adjuvant chemotherapy using 14-day dosing intervals: either (a) three cycles of doxorubicin 80 mg/m(2) as i.v. bolus followed sequentially by three cycles of paclitaxel 200 mg/m(2) as a 24-h infusion and then by three cycles of cyclophosphamide 3.0 g/m(2) as a 1-h infusion (arm A); or (b) the same schedule of doxorubicin followed by three cycles of concurrent cyclophosphamide and paclitaxel at the same doses (arm B). All cycles were supported by granulocyte colony-stimulating factor administration. RESULTS: Forty-one patients were assessable for toxicity and feasibility; 37 (90%) completed all planned chemotherapy. There was no treatment-related mortality; however, increased toxicity was observed on arm B compared with arm A, manifested by an increase in hospitalization for toxicity, mainly neutropenic fever, and an increased incidence of transfusion of packed RBCs transfusions for anemia. The mean delivered dose intensities for paclitaxel and cyclophosphamide were significantly greater for arm A compared with arm B (P =.01 and P =.05, respectively). There is no long-term, treatment-related toxicity, and no cases of acute myelogenous leukemia or myelodysplastic syndrome have been observed. CONCLUSIONS: Dose-dense sequential single-agent chemotherapy is more feasible than doxorubicin with subsequent concurrent paclitaxel and cyclophosphamide.     

Low-dose X-ray therapy for COVID-19: lessons from the past

Coronavirus disease 19 (Covid-19) poses a huge threat to health systems and economies worldwide. So far, there has been no proven effective treatment for SARS-CoV-2 infection. Various potential therapies, viz., immunomodulatory agents, antiviral therapy, and plasma transfusion, are undergoing clinical trials. An intensive search of the medical corpora revealed that low dose X-ray radiation therapy has been used in the past to treat interstitial pneumonia. In this article we explore a historical background of low-dose X-rays for the treatment of pneumonia and how it could be a promising therapy in treating patients with COVID-19.     

Radiofrequency ablation in the management of liver metastases from breast cancer

OBJECTIVE: Systemic chemotherapy remains the standard treatment for patients with breast cancer hepatic metastases. Resection of metastases has survival advantages in a small percentage of selected patients. Radiofrequency ablation has been used in small numbers of selected patients. This small series was undertaken to review our experience with radiofrequency ablation in the management of patients with breast cancer hepatic metastases. CONCLUSION: Radiofrequency ablation of breast cancer hepatic metastases is safe and may be used to control hepatic deposits in patients with stable or no extrahepatic disease.     

Effect of adjuvant breast cancer chemotherapy on cognitive function from the older patient’s perspective

SummaryPurpose This longitudinal prospective study describes the older breast cancer patient’s perception of the cognitive impact of adjuvant chemotherapy.Methods A total of 50 patients ≥age 65 with stage I to III breast cancer enrolled in this IRB-approved prospective study. Of the 50, 3 refused postchemotherapy testing and 2 had a cerebrovascular accident (CVA) during therapy, leaving 45 evaluable patients. The Squire Memory Self-Rating Questionnaire, given before and 6 months after chemotherapy, measured patients’ perceptions of the ability to learn new information, of working memory, and of remote learning capabilities.Results Mean age was 70 years (range 65–84). Breast cancer stages were: I (33%), II (64%), III (2%). A 51% (23/45) of study participants perceived a decline in memory from before to 6 months after completion of chemotherapy. Patients who perceived a poorer memory than average before chemotherapy were more likely to report further memory deterioration after chemotherapy (19/30, 63%) than patients who perceived that their memory was average or better than average prior to chemotherapy (4/15, 27%). The memory domain most likely to be perceived as affected was the ability to learn new information (22/45, 49%) compared to remote memory (9/45, 20%) or working memory (13/45, 29%) capabilities.Conclusion Approximately half of these older women perceived a decline in cognitive function from before to 6 months after chemotherapy. This perceived decline in cognitive function was most pronounced in patients with preexisting memory complaints. Further prospective study is needed to confirm these observations, correlate perceived memory changes with objective findings, and identify subgroups at special risk.     

Pain and deliberate self-harm: an important association

OBJECTIVE: The aim of this study was to establish how often pain was a factor contributing to an episode of deliberate self-harm. METHOD: Retrospective case note examination of all deliberate self-harm patients with concurrent medical problems admitted to a general hospital over 2 years. RESULTS: Pain was considered to be a contributory factor in the episode of deliberate self-harm in 75 (4%) of the total number of episodes of deliberate self-harm (1665) over the 2-year period. These patients were older and had higher suicide intent scores, but lower rates of previous psychiatric illness or alcohol or drug misuse than did the deliberate self-harm patients with medical problems but no pain. Although 60% had experienced pain for more than 6 months only, 8 (12%) were attending the local Pain Clinic at the time of the deliberate self-harm. CONCLUSION: We propose closer collaboration between general hospital services and local pain clinics for deliberate self-harm patients with painful disorders. Clinicians need to assess suicidal ideation and risk of self-harm when prescribing for this population.     

Comparison of cryoprecipitate with fibrinogen concentrate for acquired hypofibrinogenaemia

BackgroundThe benefits of fibrinogen concentrate in hypofibrinogenaemia have been established in congenital and has been used in acquired disorders. Most European countries have already changed their practice, using fibrinogen concentrate.MethodsWe compared the use of fibrinogen concentrate in acquired hypofibrinogenaemia to cryoprecipitate, which continues to be the standard of care in the UK. We undertook a retrospective analysis of fibrinogen increment in patients treated for acquired hypofibrinogenaemia.ResultsSixty four transfusion episodes receiving cryoprecipitate and 36 episodes receiving fibrinogen concentrate were compared. The median increment following 10 donor pools (two bags) of cryoprecipitate was 0.26 g/l, compared to 0.44 g/l following 2 g of fibrinogen concentrate.ConclusionWith its superior safety profile from infectious diseases, this provides further evidence to support the use of fibrinogen concentrate.     

Phase I Study of Nonpegylated Liposomal Doxorubicin plus Trastuzumab in Patients with HER2-Positive Breast Cancer

BackgroundThis was an open-label, nonrandomized, multicenter, 2-stage phase I trial of safety and preliminary efficacy of nonpegylated liposomal doxorubicin (NLD) in combination with trastuzumab in advanced breast cancer, with emphasis on cardiac toxicity.Patients and MethodsForty patients (median age, 48 years; range, 30–74 years) with HER2/neu 2+ or 3+ tumors (by immunohistochemistry) were recruited December 1999 to November 2002. Patients were eligible if they received ≤ 1 previous trastuzumab regimen, ≤ 2 cytotoxic regimens for advanced breast cancer, and lifetime cumulative anthracycline doses ≤ 240 mg/m². The study regimen comprised NLD 60 mg/m² every 3 weeks and trastuzumab loading dose 4 mg/kg followed by 2 mg/kg weekly. Treatment cycles lasted 21 days. Clinical cardiac assessments were performed with multigated acquisition scans every 2 cycles. Patients were evaluated for cardiac toxicity after receiving ≥ 1 cycle. Cardiac safety was assessed after completing ≥ 4 full treatment cycles.ResultsThirty out of 40 patients (75%) received ≥ 4 treatment cycles and were evaluable for cardiac safety. Five patients (13%), 4 who were doxorubicin pretreated, developed left ventricular ejection fraction reductions to < 50%, and 2 (5%) of these patients experienced clinical cardiac toxicity. Fifty percent of the patients had objective tumor responses; median progression-free survival was approximately 21 weeks. Twenty-six patients (65%) had grade 3/4 neutropenia; 2 patients experienced febrile neutropenia.ConclusionNonpegylated liposomal doxorubicin plus trastuzumab is active in HER2-positive patients with advanced breast cancer and is associated with a lower risk of cardiac toxicity than conventional doxorubicin plus trastuzumab.